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Closed Operative Treatment Often Feasible for Tongue-type Calcaneal Fractures

Key findings

  • In a case series of 56 adults with a tongue-type calcaneal fracture, minimally invasive closed reduction internal fixation mostly yielded sufficient fixation and resulted in fewer infectious complications compared with open reduction internal fixation
  • However, the need for revision was more frequent with minimally invasive surgery
  • Literature on the various treatment techniques for tongue-type calcaneal fractures is too sparse to draw definite conclusions

Tongue-type fractures extend into the subtalar joint with a secondary fracture line straight back to the posterior border of the calcaneal tuberosity. Unlike the case of other calcaneal fractures, either major type of surgical approach can be appropriate:

Open reduction internal fixation (ORIF) is the treatment of choice where mobilizing the tongue fragment is difficult. However, the development of deep infection is an important concern because the posterior tuberosity fragment can cause posterior skin and soft tissue compromise as a result of traction of the Achilles tendon.

Closed reduction internal fixation (CRIF) mitigates potential wound-healing complications because it is minimally invasive. The posterior facet is contiguous with the posterior tuberosity, so the facet can be directly manipulated through a pin inserted in the posterior tuberosity, making percutaneous reduction possible.

Quirine M.J. van der Vliet, MD, former PhD student, and Marilyn Heng, MD, MPH, orthopaedic trauma surgeon in the Department of Orthopaedics at Massachusetts General Hospital, and colleagues recently published the largest case series of tongue-type calcaneal fractures to date in The Journal of Foot & Ankle Surgery, along with a literature review. They were unable to draw definite conclusions about optimal surgical technique, but they present considerations for surgical planning.

Case Series

The case series included 56 adults (58 fractures) who underwent operative fixation of a tongue-type calcaneal fracture at one of two level I trauma centers between January 2004 and December 2015. When comparing the ORIF (n=32) and CRIF (n=24) groups, the researchers noted:

  • Wound problems in 30% vs. 12% of procedures
  • Deep infections in 12% vs. 0%
  • Need for revision in 3% vs. 16%

None of these differences was statistically significant. Infection-related amputation was necessary for two patients after ORIF. Both patients had peripheral arterial disease and diabetes, and one also had end-stage renal disease.

Systematic Review

The researchers identified 10 relevant studies published between January 1, 2000, and June 30, 2018. Only one was a randomized, controlled trial and six of the observational studies were retrospective. Seven studies reported on CRIF, all using slightly different procedures, whereas two reported on ORIF and the other compared ORIF and CRIF.

Only half the studies reported on infections, and no data on deep infections after ORIF were available.

Advice for Surgeons

Surgical treatment of a tongue-type calcaneal fracture should be individualized, taking into account fracture and patient characteristics as well as the treating surgeon's expertise.

CRIF usually yields sufficient fixation and results in relatively few infectious complications, so it should be attempted if deemed feasible, with conversion to ORIF if adequate reduction cannot be achieved.

Skin condition, fracture blisters, open fracture and systemic illness should be considered in decision-making about ORIF.

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